Health Care providers often encounter patients who are terminally ill in hospitals, long-term care facilities and in their homes. Many times, the heroic efforts attempted to extend the lives of these patients are futile and not desired by the patient or their family. Even when the patient is successfully resuscitated, the patient and family recognize that the patient may be left in a debilitating state with poor quality of life, resulting in a financial and emotional burden on the family. Meanwhile, health care workers and health care institutions may feel caught in the middle. The health care workers are concerned about the patient, but must also be concerned about medical malpractice lawsuits and vague state laws, and still deal with their own personal beliefs.

The out-of-hospital environment presents a particularly large dilemma. Because of this, many states have enacted pre-hospital DNR legislation. This legislation serves as a mechanism to address two competing interests that are equally valid. One, it allows the patient to be involved in their health care decision and secondly, protects EMS personnel from liability for honoring the patient’s wishes. If a terminally ill patient wishes to have life-prolonging procedures withheld or withdrawn in the pre-hospital environment, Pennsylvania law requires that they have a properly completed DNR order.

In June of 2002 the General Assembly of the Commonwealth of Pennsylvania enacted the Do-Not-Resuscitate Act (No. 2002-59). The purpose of this Act is to enable a patient in a terminal condition, or the patient’s surrogate to make personal decisions regarding resuscitation, including Cardiopulmonary Resuscitation in the out-of hospital setting. The DNR Act empowers a terminally ill person or the person’s surrogate to secure an out-of-hospital do-not-resuscitate bracelet or necklace that directs emergency medical services personnel in the out-of-hospital setting not to provide the person with CPR in the event of cardiac or respiratory arrest.  The DNR Act also specifies under what circumstances the surrogate of a person who was issued a declaration under the Advance Health Care Act is able to secure a DNR order, bracelet or necklace for the person if the person becomes permanently unconscious.  These provisions, supplemented by the Department of Health regulations (28 Pa. Code §§ 1051.1-1051.101), went into effect March 1, 2003, and were amended effective February 2004. 

To request an out-of-hospital DNR order, a person must be diagnosed as:

• Terminal or in a permanently unconscious condition
• Competent
• At least 18 years of age or older or, if under 18 years of age, has graduated from high school, has been married or is emancipated.

A surrogate for the patient may request an Out-of-Hospital DNR order for a patient otherwise unable to make the request themselves. The surrogate is an individual whom the law recognizes and allows to make the request. Should a surrogate request an Out-of-Hospital DNR, it is advisable to consult with Risk Management for guidance.

Only the patient’s attending physician can write the DNR order. The DNR Act defines ‘attending physician’ as the doctor who has primary responsibility for the medical care and treatment of the patient. It recognizes that a patient may have more than one attending physician. Physicians are directed to use good faith judgment in making the decision as to whether they are the patient’s attending physicians based on the medical care they provide to the patient.

If an attending physician is unwilling to write an order for a patient who qualifies for one, the physician needs to explain his/her rationale and reasonably assist the patient to secure the services of another physician who is willing to write the order and to assume primary care, if appropriate.

Prior to issuing an Out-of-Hospital DNR, the physician must disclose the following to the patient or surrogate, and document the discussion in the medical record: 

• Patient’s diagnosis is terminal or patient is in a permanently unconscious state.
• DNR orders allow the EMS provider to withhold CPR in the event of a cardiac or pulmonary arrest.  In addition to CPR, intubation, artificial ventilation, defibrillation, medications for resuscitation are prohibited.  However, the EMS provider may administer other interventions such as oxygen, suctioning or medication to provide comfort and alleviate pain.
• A DNR order is effective only if the patient possesses and displays the state-approved original DNR order (signed by a physician), bracelet or necklace.
• The patient may revoke the order at any time by destroying or not displaying the order, bracelet or necklace. 
• An EMS provider may administer CPR if there is any uncertainty about the validity of the Out-of-Hospital DNR order.

Out-of-hospital DNR orders must be written on the PA Department of Health approved form. No other DNR order forms may be used. Once completed, the original order is given to the patient with a copy placed in the medical record. In addition to issuing the order, the attending physician also may provide a state approved DNR bracelet or necklace, or both, for the patient. DNR bracelets and necklaces clearly indicate out-of-hospital DNR on their faces. To be valid, they must also include the patient’s name, the attending physician’s name, and be signed and dated by the attending physician. The physician should document on the order form and in the patient’s medical record that a necklace or bracelet was provided to the patient. 

To obtain the state-approved form, bracelets or necklaces, contact the Department’s vendor, Phillip Levin Company, 3301 Hoffman Street, Suite C. Harrisburg, PA 19110, (717 233-8844). A form to purchase out-of hospital DNR items may be downloaded at the EMT Office Internet website.

An out-of-hospital DNR order may be revoked by the patient without the physician’s approval or knowledge. Revocation may be accomplished by destroying or not displaying the order, bracelet or necklace, or by immediately conveying the decision to revoke the out-of-hospital DNR order verbally or otherwise at the time or preceding the time the patient experiences respiratory or cardiac arrest. Neither the patient’s physical nor mental condition at that time, or immediately preceding that time will be considered to void the patient’s decision to revoke the out-of-hospital DNR order. In addition, a surrogate may revoke the order verbally at the time of cardiac or respiratory arrest, but only if the original order was obtained by the surrogate.

An attending physician may write an out-of-hospital DNR for a pregnant woman only if the following conditions are met.  Both the attending physician and a second physician, who is an obstetrician, must examine the patient and document that with a reasonable degree of medical certainty, the provision of life sustaining treatment, nutrition and hydration will: 

• Not maintain the pregnant patient in such a way as to permit the continuing development and live birth of the unborn child, or
• Be physically harmful to the pregnant patient, or

Cause pain to the pregnant patient which cannot be alleviated by medication.

For additional information, please refer to the health system policy or to the Department of health website: http://www.health.state.pa.us